Renal Cell Carcinoma Presenting as Syncope due to Saddle Pulmonary Tumor Embolism.

Pulmonary embolism (PE) is defined as the obstruction of the pulmonary artery or one of its branches by a blood clot, tumor, air, or fat emboli originating elsewhere in the body. A saddle PE occurs when the obstruction affects the bifurcation of the main pulmonary artery trunk. We present a case of a 46-year-old man who presented to our hospital due to an episode of syncope. Computed tomography angiography (CTA) of the chest showed extensive PE and abdominal CT scan showed a large 8 cm left renal mass with inferior vena cava (IVC) thrombus. Emergent embolectomy, left total nephrectomy, and IVC tumor removal were performed yielding the diagnosis of clear cell renal cell carcinoma (RCC). Interestingly, our patient did not experience any symptoms related to his RCC until the diagnosis of PE due to syncope, and the asymptomatic tumor was found out to be the possible cause of this PE due to the presence of tumor cells constituting the tumor embolus. It is thus recommended to improve the early screening process for RCC. Besides, clinicians should pay attention to patients presenting with uncharacteristic symptoms of RCC who might present with symptoms of saddle PE.

Repurposed Effect of 177Lu-DOTATATE in the Treatment of Mantle Cell Lymphoma.

Mantle cell lymphoma (MCL) is an uncommon subcategory of non-Hodgkin lymphoma (NHL). Pathogenesis primarily includes overexpression of CCND1 and SOX11 along with other molecular aberrations. Lutetium 177Lu-DOTATATE is a radiolabeled somatostatin analogue used for the treatment of gastrointestinal neuroendocrine tumors. There are no clinical data supporting the use of Lutetium 177Lu-DOTATATE in the treatment of lymphoma. We describe the case of an 84-year-old man with a history of MCL and carcinoid tumor of the lung. Following progression of the carcinoid malignancy, the patient was treated with Lutetium 177Lu-DOTATATE. After treatment, there was an overall improvement of the patient's MCL that was demonstrated by stable lymphadenopathy on serial CT scans and down-trend of the absolute lymphocyte count. Therefore, we hypothesize that 177Lu-DOTATATE might have a role and can be repurposed for treating MCL.

Metabolic Syndrome and COVID-19 Mortality Among Adult Black Patients in New Orleans.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) mortality is high in patients with hypertension, obesity, and diabetes. We examined the association between hypertension, obesity, and diabetes, individually and clustered as metabolic syndrome (MetS), and COVID-19 outcomes in patients hospitalized in New Orleans during the peak of the outbreak. RESEARCH DESIGN AND METHODS: Data were collected from 287 consecutive patients with COVID-19 hospitalized at two hospitals in New Orleans, LA from 30 March to 5 April 2020. MetS was identified per World Health Organization criteria. RESULTS: Among 287 patients (mean age 61.5 years; female, 56.8%; non-Hispanic black, 85.4%), MetS was present in 188 (66%). MetS was significantly associated with mortality (adjusted odds ratio [aOR] 3.42 [95% CI 1.52-7.69]), intensive care unit (ICU) (aOR 4.59 [CI 2.53-8.32]), invasive mechanical ventilation (IMV) (aOR 4.71 [CI 2.50-8.87]), and acute respiratory distress syndrome (ARDS) (aOR 4.70 [CI 2.25-9.82]) compared with non-MetS. Multivariable analyses of hypertension, obesity, and diabetes individually showed no association with mortality. Obesity was associated with ICU (aOR 2.18 [CI, 1.25-3.81]), ARDS (aOR 2.44 [CI 1.28-4.65]), and IMV (aOR 2.36 [CI 1.33-4.21]). Diabetes was associated with ICU (aOR 2.22 [CI 1.24-3.98]) and IMV (aOR 2.12 [CI 1.16-3.89]). Hypertension was not significantly associated with any outcome. Inflammatory biomarkers associated with MetS, CRP, and lactate dehydrogenase (LDH) were associated with mortality (CRP [aOR 3.66] [CI 1.22-10.97] and LDH [aOR 3.49] [CI 1.78-6.83]). CONCLUSIONS: In predominantly black patients hospitalized for COVID-19, the clustering of hypertension, obesity, and diabetes as MetS increased the odds of mortality compared with these comorbidities individually.

Difference of environment behind research and clinical practice between USA and Japan.

Recent studies have demonstrated that there are differences among races in efficacy, tolerance and other outcomes in oncologic care. Some of these differences may be explained by different pharmacogenetics; however, social and environmental factors that can affect oncology practice are relatively underestimated. In this review we will focus on differences in environment, education and research between Japan and the US when it comes to lung cancer clinical practice. Such social differences seem to derive from historical reasons and continue to influence clinicians and researchers who manage lung cancer. Understanding the differences might help us conduct collaborative research in the future.

Double hit: Evans syndrome after malignant thymoma treatment and parvovirus B19 infection.

Malignancies are often associated with autoimmune diseases, which are addressed by treating the underlying cancer. However, there are rare malignancies that can cause autoimmune diseases even after appropriate treatment. Our patient is a 39-year-old Hispanic man with a malignant thymoma recently treated with chemotherapy and radiation who presented with syncope and dyspnoea. He was found to be both anaemic and thrombocytopenic. His labs were consistent with autoimmune haemolytic anaemia (AIHA), except his reticulocyte count was unexpectedly low. Bone marrow biopsy supported a diagnosis of Evans syndrome, a rare autoimmune condition characterised by (AIHA) combined with immune thrombocytopenia. He was also found to have an acute parvovirus B19 infection. He was treated with steroids and RBC transfusion. His blood counts gradually returned to baseline, with improvement in symptoms. This patient's thymoma treatment and active parvovirus B19 infection likely both played a role in the development of Evans syndrome.

An Overview of Lung and Breast Cancer Using the National Cancer Database.

INTRODUCTION: The National Cancer Database (NCDB) is a clinical oncology database utilized by many researchers and clinicians internationally. We sought to investigate the various trends in data of two of the most common cancers, breast and lung, published using the NCDB. MATERIALS AND METHODS: We selected a multitude of pre-determined variables for analysis. We then performed two separate literature searches using an advanced PubMed search builder, and the data was combined to determine each variables' association with journal impact factor (IF) using both univariate and multivariate analyses. RESULTS: A total of 191 published studies were identified. We found that a journal IF > 5 was associated with a publication year prior to 2017 (univariate analysis OR 2.68, 95% CI 1.38-5.21, p-value 0.004 and multivariate analysis OR 3.47, 95% CI 1.62-7.42, p-value 0.001) and a sample size > 10,000 (univariate analysis OR 3.27, 95% CI 1.43-7.50, p-value 0.005 and multivariate analysis OR 4.68, 95% CI 1.89-11.6, p-value 0.0008). Variables such as number of authors, region, cancer type, stage, treatment outcome and treatment incidence were not significant for an association with an IF >5. CONCLUSION: Based on our data, studies published after 2017 using the NCDB were associated with a lower IF. This could suggest that the quality of the NCDB data may be declining over time, or NCDB is becoming more widely used.
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Addition of chemotherapy improves overall survival in patients with T2N0M0 non-small cell lung cancer undergoing definitive radiation therapy: An analysis of the SEER database.

OBJECTIVES: Despite recommendations by clinical guidelines, an advantage of adding systemic chemotherapy to definitive radiation in patients with early stage non-small cell lung cancer (NSCLC) has never been demonstrated by randomized or large-scale studies. This study evaluates the role of chemotherapy in T2N0M0 NSCLC patients who did not undergo surgical resection. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database, we screened for patients with T2N0M0 NSCLC who received radiation therapy without surgical resection from 2004 to 2015. T-staging was defined according to the American Joint Committee on Cancer (AJCC) 6th (Year 2004+) and 7th (Year 2010+) versions. Overall survival based on chemotherapy status was assessed by univariate and multivariate analyses. RESULTS: A total of 6075 and 3138 patients were identified for AJCC 6th (T2; 3-7cm) and 7th (T2a; 3-5 cm, T2b; 5-7 cm) version, respectively. Administration of chemotherapy was associated with younger age, male sex, non-adenocarcinoma, and high pathologic grade. Kaplan-Meier's estimates demonstrated that the chemotherapy group had a statistically significant longer five-year overall survival than the non-chemotherapy group in patients with AJCC 6th T2 (19.9% vs 15.8%, p = 0.0023) and AJCC 7th T2b (5-7 cm, 20.9% vs 13.6%, p = 0.0046) but not those with AJCC 7th T2a (3-5 cm, 24.3% vs 21.1%, p = 0.4369). Multivariate analyses also revealed that the use of chemotherapy was an independent prognostic factor in AJCC 6th T2 and AJCC 7th T2b. CONCLUSIONS: This study strongly suggests that chemotherapy may benefit non-adenocarcinoma patients with primary tumor larger than 5 cm (AJCC 8th T3) undergoing chest radiation.

Paraganglioma of the Urinary Bladder: A Rare Cause of Hypertension and Urinary Tract Infections.

Pheochromocytoma is a neoplasm, which develops from cells of the chromaffin tissues that are derived from the ectodermic neural system and mostly situated within the adrenal medulla. Approximately 15% of pheochromocytoma cases arise from extra-adrenal chromaffin tissue. Pheochromocytoma of the bladder is rare and accounts for less than 0.06% of all bladder neoplasms and less than 1% of all pheochromocytomas. We report a case of a young woman who presented with uncontrolled hypertension, recurrent urinary tract infections and micturition attacks and was found to have a metastatic bladder paraganglioma. In addition, we provide a summary table of the clinical manifestations of paragangliomas based on anatomic locations.

An Unfortunate Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Gammopathy, and Skin Change (POEMS).

POEMS syndrome is an acronym for polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes, which is a rare paraneoplastic disease of monoclonal plasma cells. A mandatory criterion to diagnose POEMS syndrome is the presence of a monoclonal plasma cell dyscrasia in which plasma cell leukemia is the most aggressive form. Early identification of the features of the POEMS syndrome is critical for patients to identify an underlying plasma cell dyscrasias and to reduce the morbidity and mortality of the disease by providing early therapy. We present a case of a 64-year-old male who presented with non-specific symptoms and was found to have primary plasma cell leukemia, which was part of his unfortunate POEMS syndrome.

Pulmonary Vein Thrombosis: A Recent Systematic Review.

The pulmonary veins (PVs) are the most proximal source of arterial thromboembolism. Pulmonary vein thrombosis (PVT) is a rare but potentially lethal disease; its incidence is unclear, as most of the literature includes case reports. It most commonly occurs as a complica-tion of malignancy, post lung surgery, or atrial fibrillation and can be idiopathic in some cases. Most patients with PVT are commonly asymptomatic or have nonspecific symptoms such as cough, hemoptysis, and dyspnea from pulmonary edema or infarction. The thrombi are typically detected using a variety of imaging modalities including transesophageal echocardiogram (TEE), computed tomography (CT) scanning, magnetic resonance imaging (MRI), or pulmonary angiog-raphy. Treatment should be determined by the obstructing pathological finding and can include antibiotic therapy, anticoagulation, thrombectomy, and/or pulmonary resection. The delay in diagnosing this medical entity can lead to complications including pulmonary infarction, pulmonary edema, right ventricular failure, allograft failure, and peripheral embolism resulting in limb ischemia, stroke, and renal infarction (RI).

When Nothing Else Works: Fresh Frozen Plasma in the Treatment of Progressive, Refractory Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema.

Angioedema is a severe form of an allergic reaction characterized by the localized edematous swelling of the dermis and subcutaneous tissues. Angiotensin-converting enzyme inhibitor-induced angioedema (ACEI-IA) is an allergic reaction that can be severe in some cases requiring advanced management measures. Fresh frozen plasma has been used off-labeled in some case reports to improve and to prevent worsening of the angioedema in a few cases of ACEI-IA. We are reporting this case to increase the awareness of physicians and to widen their therapeutic options when encountering this clinically significant condition.

A Rare Location of a Neuroendocrine Tumor.

Neuroendocrine tumors (NETs) arising in the duodenum are rare neoplasms that are often classified as indolent and have a low potential to metastasize. Although rare, multiple reports cite an increasing incidence of duodenal NETs. Symptoms are usually nonspecific and the diagnosis is made via endoscopy. Endoscopic resection is the mainstay of therapy. The prognosis is usually favorable. We describe a case of a duodenal NET that presented with vague symptoms in order to increase the awareness of this rare but increasing in frequency entity.

Beyond the bull's eye: Recognizing Lyme disease.

A rash occurs in 80% of Lyme disease cases, but only about a third of the rashes develop into a classic bull's-eye lesion. Here's what to look for and how best to treat.

An Atypical Angiomyomatous Hamartoma With Unexplained Hepatosplenomegaly.

When a patient presented with ipsilateral lymphedema of the limb, an excisional biopsy of the left inguinal lymph node showed extensive smooth muscle and vascular proliferation replacing most of the lymph node.